Basic Information
Provider Information | |||||||||
NPI: | 1700968344 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MJOS | ||||||||
FirstName: | PETER | ||||||||
MiddleName: | O | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 196276 | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995196276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072126522 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3300 PROVIDENCE DR | ||||||||
Address2: | SUITE B314 | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995084690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072123420 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 09/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1553 | AK | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | MD15151 | 05 | AK |   | MEDICAID | 162616 | 01 | AK | MEDICARE MD GROUP # | OTHER |